An understanding of evidence-based interventions can assist with the management of physician work-associated trauma within the unique setting of health care environments.
Table 1. Examples of traumatic events experienced by physicians
Figure. Psychological and behavioral responses to traumatic events
Table 2. Types of workplace violence
Table 3. Sample work-associated trauma prevention matrix
Table 4. Network of stressors to be considered during evaluation
Table 5. Interventions for work-associated traumatic stress
Joshua C. Morganstein, MD
Premiere Date: August 20, 2018
Expiration Date: February 20, 2020
This activity offers CE credits for:
1. Physicians (CME)
All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.
To goal of this activity is to understand the etiology of work-associated trauma in physicians, adverse psychological and behavioral responses, and evidence-based interventions.
At the end of this CE activity, participants should be able to:
• Describe the causes of work-associated trauma in physicians
• Understand the consequences of traumatic exposure on physicians
• Identify the interventions available for treating physicians who have been exposed to trauma
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.
CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™.
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Joshua C. Morganstein, MD, has no conflicts to report.
Lori Davis, MD (peer/content reviewer), has no conflicts to report.
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Physicians are exposed to a range of traumatic events throughout training and professional practice, including workplace violence, disasters, and hazardous exposures (Table 1). Physicians experience psychological and behavioral effects of trauma with the same range of response (eg, distress reactions, health risk behaviors, psychiatric disorders) as does the general population. An understanding of evidence-based interventions can assist with the management of physician work-associated trauma within the unique setting of health care environments.
To understand work-associated trauma, it is first necessary to properly define terms. Trauma is a physical or mental injury. The criteria for PTSD describe traumatic events as exposure to actual or threatened death, serious injury or sexual violence through direct experience, witnessing, or repeated or extreme exposure to aversive details. Traumatic stress refers to the range of distress reactions, health risk behaviors, and psychiatric disorders that can occur in response to traumatic events. Stressors are defined as external stimuli that disrupt the equilibrium of an individual.
Causes and consequences
Psychological and behavioral responses to trauma
The literature on the effects of traumatic events comes largely from studies of individual and community responses to emergency and disaster events. Most individuals exposed to traumatic events will emerge with limited or no adverse effects, promptly and effectively resuming their social and occupational roles (resilience). Some may experience an increased sense of competence, self-efficacy, and belief in their ability to manage future stressors (often termed “posttraumatic growth”). However, a sizable minority will experience a range of adverse psychological and behavioral effects, including distress reactions, health risk behaviors, and psychiatric disorders (Figure).
Distress reactions include insomnia, irritability, and distractibility. Anger, diminished sense of safety, loss of faith, and demoralization may occur. Somatic symptoms may occur, such as headaches, dizziness, and fatigue. Most who seek care present to primary care and emergency settings. Health risk behaviors include increased use of alcohol, caffeine, and tobacco to self-medicate distress symptoms. Decreased social activities and isolation occur as well, which reduce access to helpful social support networks. Intimate partner and community violence may increase as distress escalates.
Approximately 10% to 20% of individuals exposed to a traumatic event present with PTSD, although many more experience milder symptoms that can persist and become problematic. The course of PTSD varies, with symptom escalation over time. Individuals directly exposed to the traumatic event are at greatest risk for psychiatric disorders. Additional risk factors include having an attachment to primary victims, sustaining physical injuries, a personal history of developmental trauma and abuse, or other interpersonal violence.
The element of “repeated or extreme exposure to aversive details” in the DSM-5 definition of trauma typically refers to professions such as child victim units within law enforcement or other professions where exposure to the most extreme events is a routine aspect of professional work. However, the terms “secondary traumatic stress” and “vicarious traumatization” have been used to define a spectrum of psychological and behavioral responses that may result from exposure to traumatic material or the account of patients’ traumatic exposures during clinical care.
Psychiatrists, emergency physicians, and primary care physicians, among others, may experience a range of distress reactions, health risk behaviors, and other traumatic stress symptoms in response to these exposures. It is important to understand that these psychological and behavioral responses may occur for physicians in many different circumstances.
Traumatic exposures for physicians
Physicians experience reactions to injury and death throughout their careers and no specialty is immune. In a survey of 113 surgeons, one in five reported symptoms consistent with a PTSD diagnosis, and two-thirds exhibited some symptoms.1 Death of or injury to a child is a particularly traumatic event for physicians. Identification with those who have been severely harmed (“that could have been me”) increases risk for adverse psychological symptoms.
Medical errors are the third leading cause of death in the US and have the potential to occur in every specialty and every setting.2 Physicians involved in medical errors or complications can often recall distressing aspects of the event in extraordinary detail many years later and report ruminative thoughts and distressing recollections about the event that adversely affect work and sleep.
Following a disaster, health care workers may be both provider and victim. Physician disaster responders may be exposed to mass death and injury, grotesque and disturbing sensory input, and extreme distress in patients. After the Christchurch earthquake in New Zealand in 2011, approximately 10% of medical students experienced moderate to severe distress 7 months later.3
Environmental hazards include chemical, radiological, and infectious exposures both during routine medical care and disaster response. Exposure to these materials lead to a predominance of somatic symptoms, often termed multiple unexplained physical symptoms (MUPS) or multiple idiopathic physical symptoms (MIPS).4 These somatic symptoms will often be the presenting complaint when care is sought by physicians concerned about exposure or contamination. Infectious diseases may be the biggest threat. The Ebola outbreak of 2014-2015 and highly virulent strains of more common pathogens, such as influenza, have caused considerable distress in physicians and other health care providers and been associated with poor work attendance. Mass violence is a highly traumatic event for the public and health care workers involved. Mass shootings in health care settings have captured public attention and generated significant anxiety and fear. Kelen and colleagues5 reviewed media reports of hospital shooting events between 2000 and 2011 and identified 154 hospital-related shootings, of which 91 occurred inside the hospital. Motives for shooting varied, including grudge (27%), suicide (21%), and euthanizing an ill relative (14%). In 45% of hospital shootings, the victim was the perpetrator, either self-inflicted or shot by security response.
Health care providers are at a relatively higher risk of workplace injury and violence compared with other occupations. US hospitals and nursing care facilities have higher than average rates of non-fatal workplace injuries (Table 2). Verbal violence is the most common. Physical violence occurs most frequently in emergency settings where delays in care, intoxication, and psychiatric disorders account for most cases.
Bullying of health care providers is another form of violence and occurs both in person and online. Bullying is experienced by physicians in various levels of training and across disciplines. Although not generally considered a traumatic event, workplace bullying is a significant stressor associated with the development of a similar range of responses resulting from other well-characterized traumatic events. Consequently, bullying should be considered in the discussion of physicians and work-associated trauma. Physicians who are bullied may experience depression and posttraumatic stress symptoms for years following the event. In a study examining cyberbullying of medical students, fellow trainees outpaced the frequency of bullying by other personnel in the training environment by nearly three-fold.6
Physician well-being and performance can be enhanced by organizational efforts to reduce adverse effects and promote recovery; provide thorough assessment of affected individuals; and institute prompt, evidence-based intervention following traumatic events. Important considerations include education about and normalizing of response, prevention measures, effective leadership, and barriers to care. Assessment should examine a broad range of behavioral and psychological reactions to traumatic events as well as level of impairment. Evidence-based treatments focus on reducing distress, enhancing well-being, and optimizing social and occupational function.
Education on stress, normalizing responses, when to get help, and what resources exist are at the core of effective prevention of psychological impairment following traumatic events. Ensuring “adequate equipment” and “protection” increase feelings of safety and reduce perception of risk, allowing health care providers to focus on doing their jobs. It is also important to recognize traumatic events with high-risk characteristics, identify at-risk physicians and system vulnerabilities, and take mitigation steps that promote individual and organizational resilience (Table 3).
Leaders, including those who manage or supervise medical students, residents, or staff physicians, play an important role in preventing and mitigating the impact of trauma exposure. Active listening, empathy, and support reduce feelings of fear and isolation. In this way, leaders can provide the initial support to health care providers affected by traumatic events, a critical element in reducing distress and promoting recovery. Leaders need to address grief and loss that arise following traumatic events. Grief leadership is the process of recognizing and giving voice to what has been lost following traumatic events, providing a sense of hopefulness about recovery, and a positive outlook on the future.
In spite of increased awareness and understanding of mental health, stigma continues to serve as a barrier to help-seeking for physicians.7 Health care institutions can also foster a professional culture that stigmatizes the use of help-seeking resources. The requirements to monitor and restrict the practice of physicians who are found to be impaired may serve as a significant barrier to help-seeking behaviors. Health care systems can encourage provider self-identification by minimizing or eliminating measures that will be experienced as punitive, including being publicly identified, confidentiality violations, and loss of pay.
Physicians experiencing significant or impairing distress need timely assessment by personnel trained to understand the unique effects and comorbidity associated with traumatic stress. Employee Assistant Program personnel serve this role in many institutions. Some organizations utilize in-house or contracted medical providers who are able to conduct formal evaluations when traumatic stress is the presenting concern. Assessment should consider not simply the presenting concern or specific traumatic event, but the physician’s entire “network of stressors” (Table 4).
Treatment for physician work trauma includes early interventions to reduce adverse effects, preserve functioning, and decrease progression to psychiatric disease. When psychiatric disorders occur, evidence-based psychotherapy and pharmacotherapy may help reduce symptoms and functional impairment. Complementary and alternative interventions have an increasing body of evidence supporting their use in the treatment of traumatic stress. A range of behavioral self-help interventions that are patient-centered and provider supported may be used throughout. Many physicians will prefer peer support over formal intervention. A comprehensive treatment plan involves the use of interventions that address the unique circumstances of the trauma in the context of the physician’s preferences (Table 5).
The Psychological First Aid (PFA) principles serve as an evidence-based framework for interventions designed to support the well-being of individuals and communities in the aftermath of traumatic events and includes promoting the following: safety, calming, individual and community efficacy, connectedness, and hope or optimism.8 Although rigorous studies in physician populations have not been done, the utility of PFA principles can reasonably be extrapolated to the physician population and serve as an important evidence-based guide to developing appropriate interventions. Online and mobile resources as well as web-based training in PFA can help health care personnel enhance their skills to trauma response.9-11
Well-established self-help behavioral interventions for managing distress reactions include diaphragmatic breathing, progressive muscle relaxation, and guided visual imagery. These can be taught by a health care provider or learned through online or other resources by the physician who requires treatment for trauma. These interventions facilitate the essential element of calming and reducing physiological arousal. Their benefits include being easily accessible, having little or no adverse effects, and increasing patient self-efficacy.
Trauma-focused psychotherapies, such as cognitive processing therapy and prolonged exposure therapy, have the best evidence for treating trauma-related disorders. Stress inoculation training and eye movement desensitization and reprocessing have also been found to be helpful in reducing symptoms of trauma. Trauma-focused psychotherapies incorporate imaginal exposure to the traumatic event in conjunction with an examination of cognitions the physician may have about aspects of the event and their meaning.
Pharmacotherapy following a traumatic event should generally be time-limited and symptom focused. Insomnia is a nearly universal symptom following a traumatic event. Because regulating sleep is critical to reducing arousal symptoms (and promoting the “calming” element of PFA), short-term sedative-hypnotic medication may be used to relieve insomnia. Although conflicting evidence exists, some studies suggest that prazosin is effective in treating insomnia and nightmares associated with posttraumatic symptoms.
Complementary and alternative approaches to the treatment of trauma stress have an increasing body of research supporting their efficacy, and preliminary studies as well as anecdotal evidence of benefit are promising. Mindfulness practices have the most robust research base to support their efficacy. Mindfulness is the practice of purposefully focusing on what is going on in the present moment without passing judgment. Animal-assisted therapy, yoga, meditation, and acupuncture are additional alternatives that are increasingly popular and should be considered with patient preference being an important factor in considering their use.
Physician work-associated traumatic events are both common and unavoidable. Common responses to traumatic events include distress reactions, health risk behaviors, and psychiatric disorders. The goal of intervention is to reduce levels of distress in affected physicians, restore their ability to provide care, and minimize the likelihood of lasting symptoms or impairment. Interventions for traumatic stress should incorporate the principles of PFA: safety, calming, self-efficacy, connectedness, and optimism. Providing a range of patient-centered, evidence-based interventions and formal treatment options can enhance compliance and increase well-being for health care providers who have experienced traumatic events.
Disclaimer: The views expressed are those of the author and do not necessarily reflect the views of the Department of Defense, the Uniformed Services University, the Department of Health and Human Services, or the United States Public Health Service.
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Dr Morganstein is Assistant Director, Center for the Study of Traumatic Stress, Assistant Chair/Associate Professor, Department of Psychiatry, School of Medicine, Uniformed Services University, Bethesda, MD.
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10. The National Child Traumatic Stress Network. Psychological First Aid Mobile. https://www.nctsn.org/resources/pfa-mobile. Accessed June 27, 2018.
11. The National Child Traumatic Stress Network. Psychological First Aid Online. https://learn.nctsn.org/enrol/index.php?id=38. Accessed June 27, 2018.
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